2013-12-04_REPORT - M1980244

• Permit No: M1980244
• IBM Index Class Name: REPORT
• Doc Date: 12/4/2013
• Doc Name: Well Abandonment Reports for Multiple wells
• From: CC&V
• To: DRMS
• Email Name: TC1
• Media Type: D
• Archive: No

Form No.
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
For Office Use Only
GWS -09
821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
4/2012
(303) 866 -3581 Fax [phone] dwrpermitsonline(cDstate.co.us
WELL ABANDONMENT REPORT
Use to report plugging and sealing of permitted wells, monitoring and other holes. This form can be
computer generated, typed or printed in black or blue ink. Instructions and plugging standards are on
reverse side of form.
Well Permit Number of the well being plugged or
MH File Number MH- 047180 Hole ID # /Name OSABH -7 -29
Individual /Company responsible for plugging and sealing the well:
Name(s) Cripple Creek & Victor Gold Mining Co. /Marc Tidquist
Mailing Address P.O. Box 191
City, St., Zip Victor, CO 80860
Phone (area code & no.) 719- 689 -4056 Email: mtidquist @anglogoldashantina.cgg
Well (Hole) Owner:
NAME(S) Cripple Creek and Victor Gold Mining Co. Phone (include area code) 719- 689 -4056
Mailing Address, City, St., Zip P.O. Box 191; Victor, CO 80860
ACTUAL WELL LOCATION: County Teller
Property Address, City, St, Zip 2755 State Highway 67; Victor, CO 80860
SE 1/4 ofthe _aE 1/4, Sec. 17 , Twp. 15 ® N. or I] S., Range 69 ❑ E. or IF] W., 6th P.M.
Distance from Section Lines 909 Ft. from n N. or ff S., 339 Ft. from ME. or ❑ W. Line.
Subdivision Name Lot Block , Filing /Unit
Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows:
Format must be UTM, zone 12 r7l or zone 13 Units must be meters; Datum must be NAD83; Unit must be set to true north.
Easting Northing
I (we) report the existing well (hole) was plugged and sealed on the date of 09/10/2013 for the following reason(s):
❑ The well was plugged and sealed as required under Well Permit Number
❑ The well was not in use and was plugged and sealed.
Other (please explain) Area approved by DRMS for disturbance under Amendment No. 9 & 10 to Permit M1980 -244.
The well was plugged with the following materials placed at the indicated intervals:
Amount and Type of Material Method of Placement Interval
37.5 Ibs 3/8" Bentonite Hole Plug Hand Poured from 29 feet to 5 feet
9 Ibs Cement Hand Mixed and Poured from 5 feet to 0 feet
from feet to feet
Intervals of casing removed /ripped in feet from feet to feet
Report must be signed or name entered by person who performed the well plugging work or by the well owner if this person is unknown or
not reachable. I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge.
Sign or enter full name
If signing print name & title
Date (mm /dd /yyyyy)
Marc A. Tldqulst Sr. Environmental Coor.
It is the responsibility of the well owner to have the well /hole properly plugged and sealed. The Well Construction Contractor
is responsible for notifying the owner of this requirement.